Download dsm-v: disruptive behaviors, personality disorders and v

DSM-V: DISRUPTIVE
BEHAVIORS, PERSONALITY
DISORDERS AND V-CODES
STEPHEN SOLTYS, MD
PROFESSOR AND CHAIRMAN
DEPARTMENT OF PSYCHIATRY
SOUTHERN ILLINOIS UNIVERSITY
SCHOOL OF MEDICINE
DISCLOSURES
No conflicts
ATTENTION
DEFICIT/HYPERACTIVITY
DISORDER
•
Six of nine inattention symptoms and/or
•
Six of nine hyperactivity and impulsivity symptoms
•
SYMPTOMS PRIOR TO AGE 12
•
Two or more locations
•
Specify if one or the other or combined
•
Specify in partial remission
•
Specify mild, moderate, or severe
DISRUPTIVE MOOD
DYSREGULATION DISORDER
• Listed under depressive disorders
• Almost was disruptive temperament
dysregulation disorder
• Chronic severe irritability between temper
outbursts
• Diagnosis not made before 6 years of age but
must be before 10 years of age
• Not mania
OPPOSITIONAL DEFIANT
DISORDER
• While often loses temper and is often angry
and resentful, there is not the pervasive
disturbance of mood between outbursts seen
in mood dysregulation disorder
• In response to power struggle
• Tends to be a trait, very stable over time
• Daily to once per week
INTERMITTENT EXPLOSIVE
DISORDER
• Physical or verbal outburst secondary to
minor provocations
• Not directed to achieving a tangible
objective
• Not premeditated
• Degree of aggression is marked beyond
the provocation
CONDUCT DISORDER
• Repetitive pattern of violating basic rights
of others
• Childhood or adult
• With limited pro-social emotions: lack of
remorse or guilt, lack of empathy, shallow
affect, unconcerned
• Tends to be state rather than trait
phenomena
OTHER IMPULSE CONTROL
DISORDERS
• Pathological gambling moved to
addictive disorders
• Trichotillomania moved to Obsessive
Compulsive disorders
• Pyromania and Kleptomania are in
the disruptive, impulse control and
conduct disorders and little changed
TWO APPROACHES TO
PERSONALITY DISORDERS
• Categorical – describe phenomena or behaviors seen
with the disorder, similar to DSM-IV
• Dimensional – Describe personality functioning in
terms of identity/self-direction (self) and
empathy/intimacy (interpersonal) along with
pathological personality traits
• Inflexible/pervasive/stable at least from
adolescence/early adulthood
• Not due to substances, medical condition,
developmental stage or socio-cultural
CRITERIA A: PERSONALITY
FUNCTIONING
• Identity
• Self Direction
• Empathy
• Intimacy
• Must have difficulties in two or more of these areas
• Can difficulty in only one have clinical significance?
Zimmerman et al, J Clin Psychiatry 2012;73(1):8-12
CRITERIA B: PATHOLOGICAL
PERSONALITY TRAITS
• A trait is a tendency to feel, perceive, behave and
think in a consistent manner
• Traits exist on a spectrum often with opposing
poles
• Either end of the pole can be pathological
• Lists 5 groupings of broad trait dimensions called
domains
• Specific traits in each domain are called facets
TRAIT, SYMPTOM OR
BEHAVIOR
• Behavior – isolated aberration
• Symptom – Waxes and wanes in
intensity, sometimes there and
sometimes not
• Trait – Tendency to feel, perceive,
behave and think in a relatively
consistent manner across time and
situations
NEGATIVE AFFECTIVITY vs.
EMOTIONAL STABILITY DOMAIN
• Emotional Lability
• Anxiousness
• Separation
Insecurity
• Submissiveness
• Hostility
• Perseveration
• Depressivity
• Suspiciousness
• Restricted
Affectivity
DETACHMENT vs.
EXTRAVERSION DOMAIN
• Withdrawal
• Intimacy Avoidance
• Anhedonia
• Depressivity
• Reduced Affectivity
• Suspiciousness
ANTAGONISM vs.
AGREEABLENESS DOMAIN
• Manipulativeness
• Deceitfulness
• Grandiosity
• Attention Seeking
• Callousness
• Hostility
DISINHIBITION vs.
CONSCIENTIOUSNESS DOMAIN
• Irresponsibility
• Impulsivity
• Distractibility
• Risk Taking
• Rigid perfectionism
PSYCHOTICISM vs.
LUCIDITY DOMAIN
• Unusual beliefs and experiences
• Eccentricity
• Cognitive and perceptual
dysregulation
ANTISOCIAL PERSONALITY
DISORDER
• Egocentric identity, self-directed goal
setting based on personal gratification,
lack of empathy, using exploitation
rather than intimacy (two)
• Traits : manipulative, callous, deceitful,
hostile, risk taking, impulsive and
irresponsible (six)
• Psychopathic feature specifier or LPFS
AVOIDANT PERSONALITY
DISORDER
• Identity social inept, unwillingness to take
personal risks or pursue goals, empathy
oversensitivity to rejection/criticism,
reluctant to get involved with people (two)
• Traits: anxiousness, withdrawal,
anhedonia, intimacy avoidance (three)
• Can specify other traits if present or LPFS
BORDERLINE
PERSONALITY DISORDER
• Identity is unstable with emptiness and
dissociation, instability of self-direction,
empathy interpersonal hypersensitivity,
Intimacy characterized by intense,
unstable with over or under valuation
• Traits: emotional lability, anxiousness,
separation insecurity, depressivity,
impulsivity, risk taking, hostility (four)
• Specify other traits or LPFS
NARCISSISTIC
PERSONALITY DISORDER
• Identity exaggerated self-appraisal, selfdirection either higher than achievable or
lower than can achieve due to entitlement,
attuned to other only as needed for self,
intimacy only as serve self
• Traits: Must have both grandiosity and
attention seeking
• Specify additional traits or LPFS
OBSESSIVE-COMPLUSIVE
PERSONALITY DISORDER
• Identity from productivity and control,
self-direction rigid and inflexible, poor
empathy for other input, intimacy with
others serves to enhance productivity and
control
• Traits: rigid perfectionism, perseveration,
intimacy avoidance, restricted affectivity
(three)
• Specify additional traits or LPFS
SCHIZOTYPAL
PERSONALITY DISORDER
• Confused boundaries between self and
others, unrealistic/incoherent goals, doesn’t
understand impact on others or
misinterprets, trouble developing close
relationships (two)
• Traits: cognitive/perceptual dysregulation,
unusual beliefs, experiences, eccentricity,
restricted affectivity, withdrawal,
suspiciousness (four)
• Specify other traits or LPFS
PERSONALITY DISORDER –
TRIAT SPECIFIED
• If a patient does not meet one of the
established diagnosis but has a
personality disorder that impacts at least
two of the following areas: identity, selfdirection, empathy, intimacy
• Specify the traits or domains involved
• Specify LPFS
CATEGORICAL
DESCRIPTIONS ONLY
• Paranoid personality disorder
• Schizoid personality disorder
• Histrionic personality disorder
• Dependent personality disorder
• These may be diagnosed using the
dimensional diagnosis: Personality
Disorder (Trait Specified)
LEVEL OF PERSONALITY
FUNCTIONING SCALE
• Describes level of functioning in the
four key areas of identity, selfdirection, empathy and intimacy
• Little or no impairment 0, some 1,
moderate 2, severe 3, extreme 4
AXIS IV AND V ARE GONE
• As a result, using V-codes and
severity specifiers will be critical in
ICD-10 coding
• V-codes are much expanded and
need to be used even with the
presence of psychopathology that
was formerly coded on Axis I, II or III
V-CODES: Relationships
• Parent-child
relational problem
• Sibling relational
problem
• Upbringing away
from parents
• Child affected by
parent relational
stress
• Relationship
distress with
spouse/partner
• Disrupted family
due to
separation/divorce
• High expressed
emotion level
• Uncomplicated
bereavement
V-CODE: Abuse
• Child Physical
Abuse
• Child Sexual
Abuse
• Child Neglect
• Child
Psychological
Abuse
• Spouse/Partner
Violence, Physical
• Spouse/Partner
Violence, Sexual
• Spouse/Partner
Neglect
• Spouse/Partner
Abuse,
Psychological
• Adult Abuse by
Other
V-CODE: Social
Circumstances
• Education problem
• Problem related to
employment
• Problem related to
military deployment
• Homelessness
• Inadequate housing
• Discord with
neighbor/lodger/landlord
• Lack adequate
food/water
• Extreme poverty
• Low income
• Insufficient social
insurance/welfare
support
• Discrimination or
persecution
V-CODE: Life
Circumstances
• Phase of life
problem
• Problem living
alone
• Acculturation
difficulty
• Social exclusion or
rejection
• Victim of crime
• Conviction
• Imprisonment
• Released from
prison
• Other legal
circumstances
• Sex counseling
• Religious or
spiritual problem
V-CODE: Everything Else
• Unwanted
pregnancy
• Multiparity
• Discord with social
service provider
• Victim of
terrorism/torture
• Exposure to war or
disaster
• Lifestyle health
problems
•
•
•
•
Overweight
Non-compliance
Malingering
Borderline intellectual
functioning
• Antisocial behavior
• Lack of access to
health care